Contraceptive Use and Consistency in U.S.

Teenagers’
Most Recent Sexual Relationships

CONTEXT: Most U.S. teenage pregnancies are unintended, partly because of inconsistent or no use of contraceptives. By Jennifer
Understanding the factors associated with contraceptive use in teenagers’ most recent relationships can help identify Manlove,
strategies to prevent unintended pregnancy. Suzanne Ryan and
Kerry Franzetta
METHODS: Data on 1,468 participants in Waves 1 and 2 of the National Longitudinal Study of Adolescent Health who
Jennifer Manlove is
had had two or more sexual relationships were analyzed to assess factors associated with contraceptive use patterns senior research
in teenagers’ most recent sexual relationship. Odds ratios were generated through logistic regression. associate, Suzanne
Ryan is research
RESULTS: Many relationship and partner characteristics were significant for females but nonsignificant for males. For associate and Kerry
example, females’ odds of ever, rather than never, having used contraception in their most recent relationship in- Franzetta is research
analyst, all at
creased with the duration of the relationship (odds ratio, 1.1); their odds were reduced if they had not known their Child Trends,
partner before dating him (0.2). The odds of consistent use (vs. inconsistent or no use) were higher for females in a Washington, DC.
“liked” relationship than for those in a romantic relationship (2.6), and for females using a hormonal method instead
of condoms (4.5). Females’ odds of consistent use decreased if the relationship involved physical violence (0.5). Among
teenagers in romantic or “liked” relationships, the odds of ever-use and of consistent use were elevated among fe-
males who had discussed contraception with the partner before their first sex together (2.9 and 2.1, respectively), and
the odds increased among males as the number of presexual couple-like activities increased (1.2 for each).

CONCLUSIONS: Teenagers must use contraception consistently over time and across relationships despite pressure
not to. Therefore, they must learn to negotiate sexual and contraceptive decisions in each relationship.
Perspectives on Sexual and Reproductive Health, 2004, 36(6):265–275

Although the proportion of U.S. teenagers who have ever
had sexual intercourse has declined in the past decade, al-
most half of high school–age teenagers in 2003 were sex-
ually experienced.1 In addition, despite recent dramatic
declines,2 U.S. teenage pregnancy rates and birthrates are
much higher than those of other industrialized countries,3
and most teenage pregnancies are unintended.4 Unintended
pregnancies among sexually experienced teenagers are due
to contraceptive nonuse and contraceptive failure. A bet-
ter understanding of factors associated with consistent con-
traceptive use can help researchers, policymakers, program
administrators and service providers to identify strategies
that potentially could further reduce rates of unintended
pregnancy and childbearing among adolescents.
BACKGROUND
An emerging body of research suggests that teenagers make
decisions about contraceptive use in the context of indi-
vidual sexual relationships. For example, characteristics of
teenagers’ sexual partners and relationships influence their
likelihood of using contraceptives consistently. Findings
on a link between relationship type and contraceptive use
have been mixed. Some studies have found that teenagers
who define their relationship as romantic or their partner
as someone they are “going steady” with are more likely to
use condoms or other contraception than are those in non-
romantic or more casual relationships.5 Yet other studies
have found increased condom use and consistency in more
casual or “lower quality” relationships6 or in relationships
not involving a main partner.7 However, these studies have
not addressed whether less condom use in more serious
relationships may be accompanied by increased use of more
effective methods.
Other measures that may reflect the perceived serious-
ness of a sexual relationship also have possible implications
for contraceptive use and consistency. On average, the more
“couple-like” activities teenagers engage in before having
intercourse—including thinking about themselves as a cou-
ple; going out together, alone or in a group; and meeting
their partner’s parents—the more likely they are to discuss
contraception with their partner.8 Teenagers who discuss
contraception with their first partner before having sex are
more likely than others to use contraception at first sex9
and in their first relationship,10 which may reflect teenagers’
individual motivations to use contraception and their abil-
ity to express their needs in their relationships. Adolescents
who have relatively little familiarity with their partner when
the relationship begins are less likely to use contraceptives
with that partner than other teenagers who have a more fa-
miliar partner are with theirs, possibly because they are less

Volume 36, Number 6, November/December 2004 265

Contraceptive Use and Consistency in Teenagers’ Most Recent Relationships
comfortable discussing sex and contraception.11 In fact, fe-
males who are more comfortable communicating with men
in general report higher levels of contraceptive use than
other female youth.12
As the age difference between teenagers and their part-
ners increases, their odds of contraceptive use and con-
sistency in first relationships, in current relationships and
over time are reduced for males and females.13 Having an
older partner may reflect reduced power in a sexual rela-
tionship and reduced control over contraceptive decision-
making. Some studies have found an association between
physical violence in a dating relationship (an indicator of
extreme power differentials) and nonuse of condoms.14
Compared with teenagers who have sex relatively early
in a dating relationship, those who wait are more likely to
use contraceptives consistently,15 but they are no more like-
ly to have used a condom at their most recent sex.16 In ad-
dition, although teenagers are more likely to ever use con-
traceptives in longer relationships, maintaining consistent
use becomes increasingly difficult as the duration of the re-
lationship increases.17
In addition to being influenced by relationship and part-
ner characteristics, teenagers may have an underlying
propensity toward consistent or inconsistent contracep-
tive use. For example, in one study, consistent condom use
at one time was strongly associated with condom use later,
and an increased lifetime number of sexual relationships
was associated with reduced odds of condom use.18 More-
over, an association has been shown between younger age
at first sexual experience and reduced contraceptive use
and consistency.19
Contraceptive method choice in relationships may in-
fluence consistency of use. Teenagers using coitus-depen-
dent methods are, on average, less consistent users than
are those who use the pill.20 Teenagers using dual meth-
ods21 or hormonal methods in their first sexual relation-
ship22 are more consistent users than are teenagers using
other methods.
Several individual-level factors are associated with con-
traceptive use. Racial and ethnic minorities, especially His-
panic teenagers, report lower levels of contraceptive use
than non-Hispanic white teenagers do; moreover, higher
test scores and better self-reported grades are associated
with greater use and consistency.23 Formal sex education
may be linked to increased contraceptive use.24 Moreover,
although more frequent attendance at religious services
and stronger religious beliefs are associated with delaying
sexual initiation,25 when more religious teenagers become
sexually experienced, they often are less likely than other
teenagers to use contraception.26 Family characteristics are
also important: Living with two biological parents and hav-
ing parents with higher educational levels are associated
with increased use among teenagers.27
Although males may play an important role in sexual and
contraceptive decision-making in relationships, few studies
have examined gender differences in factors associated with
contraceptive use and consistency. Meanwhile, different fac-
266
tors may be important for males and females. For example,
females with positive self-perceptions and high levels of com-
munication report increased contraceptive use, as do males
reporting high relationship quality and those with relative-
ly nontraditional attitudes regarding gender roles.28
OBJECTIVES AND HYPOTHESES
This article builds on prior research on contraceptive use
in several ways. First, we examine contraceptive use and
consistency throughout teenagers’ most recent sexual re-
lationship instead of examining only contraceptive use at
most recent sex. Second, we examine how characteristics
of teenagers’ relationships and sexual partners influence
contraceptive use and consistency. Third, we test whether
contraceptive use in teenagers’ first sexual relationship and
other characteristics of their sexual history are associated
with current use, net of most recent partner and relation-
ship factors. Fourth, we compare factors associated with
contraceptive use among males versus females. Finally, we
test for potential sample selection bias.
We examine five hypotheses: that characteristics of the
most recent sexual relationship and partner are associat-
ed with contraceptive use in that relationship; that con-
traceptive use and consistency in first relationships will be
associated with contraceptive use in most recent relation-
ships and that as teenagers’ number of sexual relationships
increases, their consistency of use decreases; that users of
hormonal methods and dual methods are more consistent
users than those who rely on other methods and single
methods are; that family and individual characteristics are
associated with contraceptive use and consistency; and that
predictors of contraceptive use and consistency will differ
by gender.
METHODS
Data Source
Data for this study come from the National Longitudinal
Study of Adolescent Health (Add Health), a nationally rep-
resentative school-based survey of U.S. adolescents in grades
7–12 in 1995.29 Add Health has involved three waves of
in-home interviews and several data collection components.
At Wave 1, in 1995, more than 20,700 adolescents and their
parents completed in-home interviews, answering a wide
range of detailed questions about health behaviors, rela-
tionships and parent-child interactions. Approximately
14,700 students were reinterviewed for Wave 2 in 1996,
and 15,200 at Wave 3, in 2002.
For this study, information on participants’ contracep-
tive use and characteristics of their most recent sexual re-
lationship was drawn from the Wave 2 survey; individual
and family background characteristics came from the Wave
1 survey. Characteristics of teenagers’ first sexual relation-
ships came from either Wave 1 or Wave 2, depending on
the timing of the respondent’s first sex. The longitudinal
nature of the Add Health data allowed us to examine how
first sexual relationships, as well as individual characteris-
tics and partner and relationship characteristics, are asso-
Perspectives on Sexual and Reproductive Health
ciated with contraceptive use in teenagers’ most recent
relationship.
Sample
We drew our sample from 5,023 unmarried, sexually ex-
perienced adolescents who participated in both survey
waves and had valid sample weights and partner-specific
information about sexual relationships. We excluded 1,658
teenagers with only one lifetime sexual partner, because
we were interested in teenagers with multiple lifetime part-
ners; in addition, we excluded 1,612 whose first sexual re-
lationship had occurred more than 18 months before the
interview, because Add Health did not collect partner-
specific information for their first relationship. To include
independent variables measured before the most recent
sexual relationship, we excluded 151 teenagers with at least
two sexual partners before, but not since, the Wave 1 in-
terview. Furthermore, we excluded 125 teenagers with in-
complete or inconsistent partner-specific information on
dates of first sex in their relationships; this allowed us to
conclusively identify respondents’ first sexual partner.* The
1,468 adolescents in our sample reported 2–10 lifetime sex-
ual partners.† We examined characteristics only from par-
ticipants’ first and most recent sexual partnerships.
Measures
•Dependent variables. Our dependent variables were de-
rived from two questions about adolescents’ contraceptive
use with their most recent sexual partner: “Did you or [your
partner] ever use any method of birth control?” and “Did
one or the other of you use some method of birth control
every time you and [your partner] had sexual intercourse?”
Using these questions, we constructed two dichotomous
dependent variables. The first compared teenagers who had
ever used contraception with those who had never used
contraception in their most recent sexual relationship. The
second compared teenagers who had always used contra-
ception with those who had only sometimes or never used
contraception.
•Characteristics of most recent partner and relationship. We
used two measures to describe the most recent sexual part-
ner: age difference between respondent and partner, and
information on how the couple met. For the latter, we noted
whether the partner was a stranger before the relationship
began, compared with whether the couple had met through
a friend or a friend of a friend, at their school or place of
worship, or in some other way.
Our first relationship measure describes the type of re-
lationship. Respondents could identify their relationship
as romantic, “liked” (identified in Add Health as relation-
ships not defined as romantic but in which the respondents
had held hands with and kissed their partner, and had told
their partner they liked or loved him or her) or nonromantic
(relationships categorized as neither romantic nor liked).
Three characteristics describe the relationship before the
partners had sex for the first time: length of presexual re-
lationship (number of months between the start of the dat-
Volume 36, Number 6, November/December 2004
ing relationship and sexual initiation), number of couple-
like activities before first sex with most recent partner and
whether the couple had discussed contraception before
having first sex. Couple-like activities included thinking of
themselves as a couple, telling others they were a couple,
going out together (alone or in a group), exchanging “I love
you’s,” meeting each other’s parents, exchanging presents
and spending less time with friends in order to spend more
time together. Data on these three measures were collect-
ed only from teenagers in romantic or liked relationships.
Our final two measures of relationship characteristics
were physical abuse in the relationship (whether the part-
ner had pushed, shoved or thrown harmful items at the re-
spondent) and duration of the sexual relationship (num-
ber of months between first and most recent sex with the
partner).
•Sexual history. Measures of sexual history were whether
respondents were at least 15 years of age at first sex, the con-
sistency of contraceptive use in their first sexual relation-
ship (categorized as never, sometimes or always used a
method) and the total number of sexual partners.‡ In pre-
liminary analyses, we tested other characteristics of the first
relationship (i.e., relationship type, discussions about con-
traception and frequency of sex) but found no significant
association with contraceptive consistency in the most re-
cent relationship.
•Method use in most recent relationship. We created a four-
category measure of most effective method used during the
relationship: hormonal methods (the pill, implant, injectable
or contraceptive ring), condoms, other (IUD, withdrawal,
rhythm, vaginal sponge, foam, jelly, cream, suppositories,
diaphragm, contraceptive film or some other method) or
no method. (Because only 63 participants, and only 8% of
female contraceptive users, reported using a long-lasting
method, such as an injectable or implant, we grouped all
hormonal methods together.) For teenagers who reported
ever having used a method, we also measured dual contra-
ceptive use, comparing those who used two or more meth-
ods every time they used contraception with those who used
*Questions about the onset of sexual activity were repeated in several ways,
and the teenagers were not always consistent across their responses. The
multiple items regarding sexual experience included questions asking
whether the respondent had ever had sex, the date of first sexual inter-
course and the date of first sexual intercourse with specific nominated part-
ners. We excluded 67 teenagers who gave incomplete partner-specific dates
of sex, making it impossible for us to identify the first and most recent part-
ners, and 58 who had had at least two partners but whose first partner was
also their most recent partner.
†We excluded nine with missing information for the dependent variable.
Also, when data for explanatory variables were missing, we substituted
the mean or mode of the nonmissing values. Furthermore, we included a
measure of missing data in the multivariate models for measures in which
data were missing for more than 5% of respondents.
‡We also created a “missing” category for the 5% of the sample who had
provided no information on consistency of contraceptive use in their first
sexual relationship. This category had a statistically significant negative
association with always using contraception for females (not shown). In
addition, we controlled for whether respondents had begun having sex
with their first partner before Wave 1 (only 7–9% had), which was not sig-
nificantly associated with outcomes for males or females, and for the length
of time between first sex with the first and the most recent partners, which
had a statistically marginal positive association with consistent use among
females.
267
Contraceptive Use and Consistency in Teenagers’ Most Recent Relationships

TABLE 1. Selected characteristics of sexually experienced teenagers, by gender, reported score on a modified Peabody Picture Vocabulary
National Longitudinal Study of Adolescent Health, Waves 1 (1995) and 2 (1996) Test, in which the national average is 100),30 religious ser-
Characteristic Males Females vice attendance (for which scores range from zero, denot-
(N=606) (N=862) ing never or no religion, to four, for attend at least once a
Consistency of contraceptive use (%) week) and whether the respondent had received pregnancy
Never 20.7 20.2 and AIDS prevention education in school.†
Sometimes 17.8 21.4
Always 61.5 58.4
Statistical Analysis
Characteristics of most recent relationship We were interested primarily in two questions: whether
Mean no. of yrs. partner is older than respondent (range, 0–20) 0.1 2.1***
Met partner as stranger (%) 5.5 6.0 teenagers who ever used contraception in their most recent
Type of relationship (%) sexual relationship differ from those who never used a
Romantic 71.5 88.1**
Liked 11.2 9.0 method and whether teenagers who always used a method
Nonromantic 17.4 9.8 differ from those who never or only sometimes did.‡
Mean no. of mos. of presexual relationship (range, –24 to 65)‡,§ 4.3 4.5
We used chi-square statistics to test gender differences in
Mean no. of presexual couple-like activities (range, 0–8)‡ 4.9 5.4**
Discussed contraception before sex (%)‡ 41.2 55.7*** relationship and partner characteristics, and to assess bivariate
Physical violence (%) 11.1 10.1 associations between the dependent variables and these char-
Mean no. of mos. of sexual relationship (range, 1–42) 5.0 6.3**
acteristics. We then used logistic regression to analyze data
Sexual history on the full sample. In supplementary analyses restricted to
Aged ≥15 at first sex (%) 65.3 62.8
Consistency of contraceptive use in first relationship (%)
the 1,297 teenagers in romantic or liked relationships (re-
Never 23.4 23.4* ferred to as the romantic sample), we included measures not
Sometimes 13.6 21.5 asked of adolescents in nonromantic relationships.
Always 63.0 55.1
Mean lifetime no. of partners (range, 2–10) 3.3 3.3 To examine method type and dual method use, we used
logistic regression to compare teenagers who always ver-
Contraceptive use in most recent relationship (%)
Most effective method used sus sometimes used contraception. All analyses were con-
Hormonal 18.3 33.6*** ducted separately for males and females, and were weight-
Condom 58.4 43.7
ed and adjusted for the data’s clustered sampling design
Other 1.8 2.0
None 21.6 20.8 by using survey estimation procedures in Stata.31
Dual method use (%) 25.6 25.0 We expected that the teenagers in our sample might dif-
Family characteristics fer systematically from sexually experienced teenagers who
Two biological/adoptive parents (%) 40.5 41.7 were excluded (including those who had had only one sex-
Mean parental education (range, 1–7)†† 4.6 4.5
ual partner and those for whom data on first sexual expe-
Individual characteristics rience had not been collected).§ Therefore, we tested for po-
Race/ethnicity (%) tential sample selection effects using probit Heckman models
White 61.2 67.1†
Hispanic 14.4 9.1 in Stata to adjust for selection characteristics. The rho val-
Black 17.9 18.6 ues for the selection equations were not significant in any
Asian 1.8 2.2
Other 4.8 3.1 models, indicating that our sample did not differ from other
Mean cognitive test score (range, 13–131)‡‡ 101.7 100.1† sexually experienced respondents on preexisting family and
Mean religious services attendance (range, 0–4)§§ 1.5 1.9***
Had pregnancy/AIDS education in school (%) 87.0 88.3
individual characteristics. Consequently, we felt confident
using models without an adjustment for sample selection.
*p<.05. **p<.01. ***p<.001. †p<.10. ‡Among the 1,297 respondents with a romantic or liked partner. §Negative
numbers in the range reflect that among the teenagers in a romantic or liked relationship, some respondents
reported that they had had sex with their partner at an earlier date than they considered their romantic/liked RESULTS
relationship to have begun. ††Highest educational level attained by a parent; 1=less than high school, 7=at least Characteristics of Participants
some graduate or professional school. ‡‡Modified Peabody Picture Vocabulary Test. §§0=never (or no religion),
4=at least once per week. Notes: Data are weighted. Significance tests for categorical variables measure between- A majority of males and females (62% and 58%, respec-
group differences among all categories. tively) reported consistent use of contraception in their most
recent relationship, 20–21% reported no use and the re-
a single method or only sometimes used dual methods. Of maining 18–21% reported inconsistent use (Table 1).
note, inconsistent contraceptive users could have been clas-
sified as dual method users if they had used two or more *Throughout this article, white and black refer to non-Hispanic white and
non-Hispanic black.
methods every time they had used contraception.
†Teenagers were asked whether they had learned about pregnancy and
•Family and individual characteristics. Family characteris- AIDS in a class at school, but there was no opportunity to report when they
tics controlled for in our analyses were family structure (two received this education or the content of the class.
biological or adoptive parents vs. all others) and parental ‡Males may not accurately report whether their partner used hormonal
education; the scale for the latter variable ranged from a methods. Therefore, we performed additional analyses (not shown) for
males’ reports of relationships using only coitus-specific methods; results
score of one (never completed high school) to seven (at least
were similar to those reported here.
some graduate or professional school). Individual charac-
§In bivariate analyses (not shown), sexually experienced teenagers excluded
teristics were race or ethnicity (Hispanic, white, black,* Asian from our sample were less likely than those in our sample to have first had
or other), cognitive ability (measured by respondents’ self- sex before age 15.

268 Perspectives on Sexual and Reproductive Health

 TABLE 2. Selected characteristics of teenagers, by consistency of contraceptive use in most recent sexual relationship and
gender
Characteristic Use never vs. ever Use never/sometimes vs. always
Males Females Males Females
Never Ever Never Ever Never/ Always Never/ Always
(N=123) (N= 483) (N=173) (N=689) sometimes (N=377) sometimes (N=503)
(N=229) (N=359)
Consistency of use (%)‡
Never 100.0 100.0 100.0 0.0 53.8 0.0 48.7 0.0
Sometimes 0.0 22.4 0.0 26.8 46.2 0.0 51.4 0.0
Always 0.0 77.6 0.0 73.2 0.0 100.0 0.0 100.0

Characteristics of most recent relationship

Mean no. of yrs. partner is older
than respondent 0.1 0.1 2.1 2.1 0.0 0.1 2.2 2.1
Met partner as stranger (%) 5.4 5.5 13.8 4.1*** 3.8 6.5 8.3 4.4*
Type of relationship (%)
Romantic 71.2 71.5 79.7 81.6 78.4 67.1† 85.1 78.5*
Liked 10.3 11.4 6.5 9.7 9.7 12.0 5.0 11.9
Nonromantic 18.5 17.1 13.8 8.7 11.9 20.9 9.9 9.6
Mean duration of presexual
relationship (mos.)‡ 3.2 4.6 4.5 4.5 3.8 4.7 4.5 4.5
Mean no. of presexual
couple-like activities‡ 3.7 5.2*** 4.8 5.6** 4.6 5.1 5.2 5.6
Discussed contraception
before sex (%)‡ 30.3 44.0* 34.8 60.7*** 38.4 43.2 47.3 61.6**
Physical violence (%) 14.5 10.2 11.3 9.7 15.4 8.3* 14.1 7.2**
Mean duration of
sexual relationship (mos.) 4.2 5.3 4.3 6.8*** 6.1 4.4* 7.0 5.9*

Sexual history (%)

Aged ≥15 at first sex 61.0 66.5 72.1 60.5* 63.5 66.4 65.1 61.2
Contraceptive use in first relationship
Never 38.2 19.4* 37.5 19.8** 28.1 20.3** 28.3 20.0**
Sometimes 16.0 12.9 21.8 21.4 20.5 9.0 28.5 16.6
Always 45.8 67.7 40.7 58.8 53.1 70.7 43.2 63.4
Mean lifetime no. of partners 3.2 3.3 3.5 3.3 3.2 3.3 3.6 3.2***

Contraceptive use in most recent relationship (%)§

Most effective method used
Hormonal na 23.3 na 42.4 23.5 23.3 25.7 48.6
Condom na 74.4 na 55.1 75.4 74.1 69.7 49.6
Other na 2.3 na 2.6 1.1 2.7 4.6 1.8
Dual method use na 25.6 na 25.0 26.8 25.2 15.7 28.5**

Family characteristics
Two biological/adoptive
parents (%) 35.0 42.0 44.2 41.1 33.8 44.7* 45.2 39.2
Mean parental education†† 4.6 4.6 4.3 4.5 4.5 4.7 4.4 4.5

Individual characteristics (%)

Race/ethnicity
White 59.5 61.6 60.1 68.9 66.7 57.7* 65.4 68.2
Hispanic 13.4 14.7 14.3 7.8 13.6 14.9 10.6 8.0
Black 22.0 16.8 18.8 18.5 15.8 19.2 7.9 19.1
Asian 3.5 1.3 4.1 1.8 2.5 1.3 2.9 1.8
Other 1.7 5.6 2.8 3.1 1.4 6.9 3.2 3.0
Mean cognitive test score‡‡ 97.9 102.7* 98.1 100.6† 100.1 102.7† 100.0 100.2
Mean religious services
attendance§§ 1.1 1.6** 1.8 2.0 1.3 1.7** 1.9 2.0
Had pregnancy/AIDS
education in school (%) 84.8 87.5 90.7 87.7 87.8 86.4 89.7 87.4

*p<.05. **p<.01. ***p<.001. †p<.10. ‡Among the 1,297 respondents with a romantic or liked partner. §Among the 1,172 respondents reporting any method use.
††Highest educational level attained by a parent; 1=less than high school, 7=at least some graduate or professional school. ‡‡Modified Peabody Picture Vocabu-
lary Test. §§0=never (or no religion), 4=at least once per week. Notes: na=not applicable. Data are weighted. Significance tests for categorical variables measure
between-group differences among all categories.

Females reported a significantly greater age difference
between themselves and their partners than did males (two
years, on average, compared with less than one). Six per-
cent of males and females had met their most recent part-
ner as a stranger; a higher proportion of females than males
described their most recent sexual relationship as roman-
tic (88% vs. 72%). On average, teenagers’ most recent dat-
ing relationship had lasted about four months before the
couple began having sex. Females reported more presex-
ual couple-like activities than males did; females also were
more likely than males to have discussed contraception with
their most recent partner. One in 10 males and females re-

Volume 36, Number 6, November/December 2004 269

Contraceptive Use and Consistency in Teenagers’ Most Recent Relationships

TABLE 3. Odds ratios from logistic regression analyses Bivariate Analyses

assessing associations between selected characteristics •Ever-use versus never-use. Males who had ever used con-
and teenagers’ use of contraceptives ever and always in traception in their most recent relationship had engaged
their most recent sexual relationship, by gender
in more presexual couple-like activities, and were more like-
Characteristic Use ever Use always ly to have discussed contraception before sex, than never-
(vs. never) (vs. never/
sometimes) users (Table 2, page 269). Participants who had ever used
contraception were more likely than others to have always,
Males Females Males Females
(N=606) (N=862) (N=606) (N=862) and less likely to have never, used contraception in their
Most recent relationship
first relationship. Almost half of males who had never used
No. of yrs. partner is a method in their most recent sexual relationship report-
older than respondent 1.06 1.00 1.02 0.98 ed consistent use in their first relationship, indicating con-
Met partner as stranger 1.05 0.21** 1.97 0.49†
Type of relationship siderable variation in contraceptive use across relationships.
Romantic (ref) 1.00 1.00 1.00 1.00 On average, ever-users had a higher cognitive test score and
Liked 1.53 2.02† 1.39 2.57**
Nonromantic 0.94 0.66 1.70 0.97 a higher level of religious service attendance than never-
Physical violence 0.82 0.65 0.70 0.49* users.
Duration of sexual
Compared with females who had never used contra-
relationship 1.05 1.11** 0.97 0.99
ceptives in their most recent relationship, female ever-users
Sexual history were less likely to have met their partner as a stranger and
Aged ≥15 at first sex 1.48 0.49** 1.40 0.77
Consistency of contraceptive had more presexual couple-like activities, a greater likeli-
use in first relationship hood of having discussed contraception with their partner
Never 0.34* 0.36** 0.55 0.49**
Sometimes 0.49 0.52† 0.31** 0.36**
before sex and longer sexual relationships. Ever-users were
Always (ref) 1.00 1.00 1.00 1.00 less likely than never-users to have been aged 15 or older
Lifetime no. of partners 1.03 0.85† 1.08 0.80** at first sex. Compared with never-users, females who had
Family characteristics ever used contraception were more likely to have always,
Two biological/ and less likely to have never, used contraception with their
adoptive parents 1.23 1.03 1.64* 0.81
Parental education 0.93 1.07 1.01 1.03 first sexual partner. Participants who had ever used con-
traception had marginally higher cognitive test scores than
Individual characteristics
Race/ethnicity
never-users.
White (ref) 1.00 1.00 1.00 1.00 •Consistent use versus inconsistent or no use. Compared with
Hispanic 1.09 0.53* 1.32 0.65 males who had never or sometimes used a method in their
Black 0.92 0.71 1.39 0.77
Asian 0.53 0.42 0.47 0.82 most recent relationship, male consistent users were mar-
Other 2.93 1.46 4.68* 0.97 ginally less likely to consider their partner a romantic part-
Cognitive test score‡ 1.03* 1.01 1.01 1.00
Religious services ner and marginally more likely to have been in a liked or
attendance 1.30* 1.09 1.17† 1.01 nonromantic relationship. In addition, males who had al-
Had pregnancy/AIDS ways used contraception in their most recent relationship
education in school 1.47 0.68 0.96 0.61
reported a lower level of physical violence and a shorter
F statistic 1.79* 5.42*** 2.34** 2.89*** sexual relationship. Male consistent users were more like-
df 22 22 22 22
ly to have always, and less likely to have never, used con-
*p<.05. **p<.01. ***p<.001. †p<.10. ‡Modified Peabody Picture Vocabulary Test. traception in their first sexual relationship. They also were
Notes: ref=reference category. df=degrees of freedom. Data are weighted. The
model controls for whether respondent had had sex before Wave 1 and for time
more likely to live with two biological or adoptive parents,
between first sex with first partner and first sex with most recent partner. were less likely to be white and more likely to be black or
of “other” race, had marginally higher cognitive test scores
ported experiencing physical violence in their most recent and had higher levels of religious service attendance than
sexual relationship. On average, females’ relationships had nonusers and inconsistent users.
lasted longer than males’ relationships. Female consistent users, compared with female nonusers
Two-thirds of both males and females had been aged 15 or inconsistent users, were less likely to have met their part-
or older at first sex. Sixty-three percent of males and 55% ner as a stranger, less likely to be in romantic and more like-
of females reported consistent use of contraception with ly to be in liked relationships, and more likely to have dis-
their first sexual partner. Both males and females had had cussed contraception before first sex with their partner. They
an average of 3.3 lifetime sexual partners. Females were more also were less likely to report physical violence, and on av-
likely than males to report that the most effective method erage, they reported a shorter sexual relationship. Consis-
used with their most recent partner had been a hormonal tent users were more likely to have always used contra-
method (34% vs. 18%). In contrast, 58% of males report- ception, and less likely to have never used contraception,
ed that condoms had been the most effective method used with their first sexual partner, compared with nonusers and
with their most recent partner, compared with 44% of fe- inconsistent users; they also reported fewer lifetime sexu-
males. Finally, females reported more frequent attendance al partners and were more likely to have used dual meth-
at religious services than males did. ods with their most recent sexual partner.

270 Perspectives on Sexual and Reproductive Health

TABLE 4. Odds ratios from logistic regression analyses
assessing associations between selected characteristics and
teenagers’ use of contraceptives ever and always in their
most recent romantic or liked sexual relationship, by gender
Characteristic Use ever Use always
(vs. never) (vs. never/
sometimes)
Males Females Males
(N=512) (N=785) (N=512)
Duration of presexual
relationship 1.02 0.99 1.02
No. of presexual
couple-like
activities 1.24*** 1.04 1.18**
Discussed contra-
ception before sex 0.89 2.94** 0.76
F statistic 2.89*** 3.99*** 2.51***
df 25 25 25
**p<.01. ***p<.001. Notes: df=degrees of freedom. Data are weighted. The model
includes all other covariates shown in Table 3.
Multivariate Analyses
•Ever-use versus never-use. For males, none of the charac-
teristics specific to the most recent sexual relationship were
significant, net of family, individual and first relationship
factors (Table 3). However, never-use during males’ first
sexual relationship was associated with 66%-reduced odds
of ever-use in their most recent relationship (odds ratio,
0.3). Two individual characteristics were associated with
increased odds of contraceptive use: The higher the cog-
nitive test score or the more frequent males’ attendance at
religious services, the greater their likelihood of ever hav-
ing used a method (1.03 and 1.3, respectively).
For females, relationship characteristics associated with
contraceptive use in the most recent relationship were prior
familiarity with partner and length of the relationship. The
odds of ever-use were reduced if females’ most recent part-
ner had been a stranger to them (odds ratio, 0.2) and in-
creased by 11% for each additional month of the relation-
ship (1.1). Relationship type was marginally associated with
the outcome of interest.
Two aspects of sexual history were significantly related
to females’ contraceptive use. Teenagers who were older at
first sex had reduced odds of ever having used contracep-
tion (odds ratio, 0.5). This finding seems counterintuitive,
but it supports results of the bivariate analysis and remained
robust across numerous alternate model specifications.*
Also, females had reduced odds of ever having used con-
traception in their most recent relationship if they had never
used contraception in their first relationship (0.4). Con-
traceptive inconsistency in the first relationship and num-
ber of lifetime partners were marginally associated with
lower odds of contraceptive use.
Ethnicity was the only individual characteristic that pre-
dicted contraceptive use for females: Hispanic females had
lower odds of ever having used contraception (0.5), com-
pared with whites.
The predictors of contraceptive use with the most recent
partner differed substantially by gender. Only the negative
association with never-use in the first sexual partnership
Volume 36, Number 6, November/December 2004
was significant for both males and females. (Assessment
of gender differences was based on whether different fac-
tors were significantly associated with contraceptive use
and consistency for males compared with females.)
•Consistent use versus inconsistent or no use. For males, con-
traceptive use in the first sexual relationship was associat-
ed with consistency of use with the most recent partner.
Females
(N=785) Males who only sometimes used contraception in their first
relationship had 69%-reduced odds of always using con-
0.99 traception in their most recent relationship.
Two family and individual background characteristics
1.02 were related to contraceptive consistency. Males who lived
in an intact family or who are of “other” race had elevated
2.07**
2.72*** odds of always using contraception. (The relatively high
25 odds of “other” race was probably driven by the small cell
size—only 18.) Moreover, for males a higher level of religious
service attendance was marginally associated with elevat-
ed odds of contraceptive consistency.
Relationship characteristics associated with females’ con-
traceptive consistency in their most recent partnership were
relationship type and violence. Teenagers in a liked rela-
tionship had higher odds of being consistent contracep-
tive users (odds ratio, 2.6), compared with those who con-
sidered their relationship romantic. In contrast, the odds
of always using contraception were reduced by half if there
was physical violence in the relationship (0.5). Having lit-
tle familiarity with the partner before the relationship began
had a marginally negative association with contraceptive
consistency.
Among sexual history characteristics, consistency of con-
traceptive use with the first partner and number of lifetime
partners were related to females’ consistency of use with
their most recent partner. Both never and sometimes using
contraception in the first relationship were associated with
reduced odds of consistent use in the most recent rela-
tionship (odds ratios, 0.5 and 0.4, respectively). Likewise,
the odds of always using contraception were reduced by
20% for each additional partner that a female teenager had
had (0.8). No family or individual characteristics were as-
sociated with contraceptive use consistency for females.
There was very little similarity between male and female
predictors of always using contraception in the most re-
cent relationship. Only contraceptive use in the first rela-
tionship was significant for both, as in the analysis of ever-
use versus never-use.
•Romantic sample. We restricted our next analysis to the
romantic sample, to examine the critical measures asked
only of teenagers in romantic or liked relationships (Table
4). For males, engaging in more couple-like activities was
associated with elevated odds of both ever having used con-
*We believe the association with age is because in our sample, the youngest
teenagers were more likely than teenagers aged 15 or older to report hor-
monal method use. We also constructed alternate models: one specifying
age at first sex as a continuous variable, a second dividing it into different
numbers of categories, a third using age at first sex with most recent part-
ner instead of time between relationships, a fourth removing the indica-
tor for survey wave in which the teenager first reported sex (in case it was
functioning as a proxy for age at first sex), and a fifth including only indi-
vidual and family characteristics.
271
Contraceptive Use and Consistency in Teenagers’ Most Recent Relationships
traception (odds ratio, 1.2) and always having used con-
traception (1.2). For females, having discussed contra-
ception before sex was associated with elevated odds of
ever-use and consistent use (2.9 and 2.1, respectively).
•Method use and contraceptive consistency. We also exam-
ined whether method choice was associated with consis-
tency of contraceptive use. We restricted this analysis (not
shown) to adolescents who had sometimes or always used
contraception, and included two additional measures: most
effective method used during the relationship and dual
method use.
For males, consistency of contraceptive use did not differ
by method type. However, among females, the odds of al-
ways having used contraception were more than four times
as high for hormonal users as for those whose most effective
method had been condoms (odds ratio, 4.5). Of note, 84%
of hormonal users were using the pill; thus, this association
is not explained by use of long-lasting methods. Dual method
use had no association with consistency for either gender.
DISCUSSION
This research builds on earlier studies suggesting that de-
cisions about contraceptive use are made in the context of
particular sexual relationships and that characteristics of
partners influence whether teenagers ever or always use
contraception.
Our study has some limitations. Teenagers provided in-
formation on partner characteristics and contraceptive use
retrospectively, whereas contraceptive use would ideally be
measured by using daily calendars. Fortunately, however, the
time between Waves 1 and 2 was relatively short, limiting
possible recall bias. Also, Add Health incorporated audio
computer-assisted self-interviews to help improve the valid-
ity of reports of risky or sensitive behaviors,32 and analyses
of Add Health reports of sexual behaviors and sexually trans-
mitted diseases suggest they are valid measures.33 In addi-
tion, because our sample is restricted to respondents with
two or more sexual relationships, our findings apply to
teenagers whose risk of unintended pregnancy may be high-
er than that of teenagers who have had only one relationship.
Relationship and Partner Characteristics
Consistent with other studies showing a link between un-
familiarity with a partner and reduced contraceptive use,34
our study indicates that females whose most recent sexu-
al partner was a stranger to them when they started dating
are less likely than females who met their partner through
school, friends or church to have ever or always used con-
traception. This finding suggests that females who do not
know their partner through social networks may be less
able or willing than others to communicate their repro-
ductive health needs or to plan for sex.
How teenagers define their relationship and the types
of intimate, couple-like activities in the relationship are also
associated with contraceptive use and consistency. Females
in romantic relationships have lower odds than those in
liked relationships of ever or always having used contra-
272
ception. This finding matches results of previous studies
suggesting that teenagers may be less careful about con-
traception when they are in more committed relationships;35
however, it contradicts previous findings of greater con-
traceptive use in romantic than in liked first relationships.36
Program providers should address the possibility that de-
cisions on contraceptive use are compromised by teenagers’
needs for intimacy.37 Females, in particular, may jeopar-
dize contraceptive protection for an intimate male partner.
In contrast, males in romantic or liked relationships who
engage in more couple-like activities with their partner be-
fore having sex are more likely to use contraception, sug-
gesting a protective effect of intimate relationships with
stronger couple identities.
Having a physically violent partner is associated with re-
duced consistency of contraceptive use among females. Al-
though a small proportion of teenagers in our sample
reported violence, its observed link with reduced contra-
ceptive use confirms prior research38 and demonstrates
the need for providers to explore adolescents’ needs re-
garding violence and abuse prevention.
Females, but not males, in romantic or liked relationships
who report discussing contraception with their sexual part-
ner before onset of sexual relations are more likely to have
ever and always used contraception with that partner. This
finding highlights the importance of allowing teenagers,
especially females, to practice negotiation and refusal skills
through role-playing exercises, a primary component of ef-
fective pregnancy prevention programs.39
Relationship duration is also associated with consisten-
cy of contraceptive use: Females are more likely to have ever
used contraceptives as the duration of their sexual rela-
tionship increases. Other studies have likewise shown that
as relationship duration increases, teenagers become more
likely to use contraception, although maintaining consis-
tency over time may become increasingly difficult.40
Two variables that we hypothesized would be associat-
ed with contraceptive consistency—age difference between
teenagers and their partners and duration of presexual re-
lationship—had nonsignificant findings. Other relationship
and partner characteristics may more substantially influ-
ence contraceptive decision-making in teenagers’ most re-
cent relationship.
Sexual History
As hypothesized, contraceptive use in the first and most
recent sexual relationships are linked: Compared with
teenagers who always used contraception in their first re-
lationship, teenagers who had not used contraception in
their first relationship or who had used it inconsistently
had reduced odds of ever and always having used contra-
ception in their most recent relationship. However, sub-
stantial variation in contraceptive consistency exists across
individuals. For example, one in five teenagers who reported
consistent contraceptive use in their most recent sexual re-
lationship had used no method in their first relationship.
In contrast, 40–45% of teenagers who had never used a
Perspectives on Sexual and Reproductive Health
method in their most recent relationship reported that they
had always used contraception in their first relationship.
Thus, pregnancy prevention programs must help teenagers
learn to better negotiate sexual and contraceptive decisions
in each new relationship.
Among females, having more lifetime partners is asso-
ciated with reduced odds of always using contraception.
This finding suggests that teenage females experience “con-
traceptive fatigue” across relationships, and that females
in greatest need of protecting themselves and their part-
ners from unintended pregnancy (and sexually transmit-
ted diseases) are the least likely to have engaged in protective
behavior. Pregnancy prevention programs and family plan-
ning providers should thus highlight the importance of
using contraception consistently across relationships.
The observed association for teenagers’ age at first sex
seems to operate in a counterintuitive direction for females.
Teenage females who are younger at first sex are more like-
ly to have ever used contraception. This finding seems to
reflect the higher rates of hormonal method use in female
teenagers’ most recent sexual relationship among those who
were 14 or younger at sexual initiation (not shown), pos-
sibly because of early interventions or simply misreport-
ing method type.
Method Choice
Our analyses show that hormonal method use is associat-
ed with increased consistency of contraceptive use among
females. Earlier findings41 of no link between hormonal
method use and adolescent females’ consistency of con-
traceptive use in their first sexual relationship may reflect
that few teenagers begin their first relationship using hor-
monal methods. Hormonal use becomes more prevalent
in later relationships; however, only one-third of females
in our study reported having used a hormonal method, and
an even smaller proportion of males reported that their fe-
male partner had used one. The most recently developed
hormonal methods—injectables and the contraceptive
patch—combine consistency and effectiveness, and may be
the most effective methods to promote for sexually active
teenagers.42 However, only a small proportion of teenagers
in our sample reported having used a long-lasting method.
Family and Individual Characteristics
Among males, higher cognitive test scores are associated
with greater contraceptive use, as other research also has
suggested.43 Of interest, males with a higher level of reli-
gious service attendance are more likely to have ever and to
have always used contraception, which counters other stud-
ies in which religious attendance has been associated with
reduced contraceptive use.44 The positive link between re-
ligiosity and contraceptive use in our study may reflect—
among religious males, in particular—a high level of perceived
social sanctions against premarital pregnancy. By contrast,
more religious females are no more likely than other females
to use contraception consistently, even though they also may
have strong motivations to avoid pregnancy.
Volume 36, Number 6, November/December 2004
Gender Differences
Factors associated with contraceptive use and consisten-
cy differ for males and females. For males, more family and
individual characteristics than relationship and partner char-
acteristics are associated with contraceptive use and con-
sistency, whereas for females, more relationship and part-
ner characteristics and choice of method are associated with
contraceptive use and consistency. Because females are more
likely than males to define their sexual relationships as ro-
mantic, these findings may reflect that females place greater
importance on intimate relationships than males do. More-
over, because males may play an important role in couples’
contraceptive decision-making, pregnancy prevention pro- Parents,
grams must expand their focus on male involvement; how-
ever, few evaluated programs have curricula developed
policymakers,
specifically for males.45
providers and
Policy Implications teenagers must
Large proportions of sexually experienced teenagers are
not consistent contraceptive users, and those who use con- continue to
sistently in one relationship may not do so in another. Eval-
uations of pregnancy prevention programs have found that address ways
many positive effects on sexual and contraceptive use be-
haviors are only short-term;46 as a result, some promising of motivating
programs are adding booster sessions to help sustain pos-
itive outcomes over time. Parents, policymakers, providers youth to avoid
and teenagers must continue to address ways of motivat-
ing youth to avoid pregnancy risk over time and across re- pregnancy risk
lationships, even in the face of potential social and partner
pressures to do otherwise.
over time and
We have highlighted multiple relationship and partner
characteristics associated with contraceptive use and con-
across relation-
sistency. Currently, the primary relationship characteris-
ships.
tics that pregnancy prevention programs focus on involve
sexual abuse or statutory rape, because of reporting re-
quirements in federally funded programs.47 Effective pro-
grams often maintain a critical focus on communication
and negotiation skills between teenagers and their part-
ners,48 and we find that communication between partners
is strongly associated with contraceptive use and consis-
tency. However, only about half of teenagers report having
discussed contraception with their most recent partner be-
fore having sex with that partner. To be effective among
teenagers, programs must also address whether power dif-
ferences in a relationship—due, for example, to not know-
ing the partner well, to experiencing physical violence in
the relationship or even to desires for intimacy—may com-
promise decision-making or negotiating skills.
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Acknowledgments
The research on which this article is based was funded by the
National Institute of Child Health and Human Development
through grant R01 HD40830-01. This research uses data from Add
Volume 36, Number 6, November/December 2004
Health, a program project designed by J. Richard Udry, Peter S.
Bearman and Kathleen Mullan Harris, and funded by a grant P01-
HD31921 from the National Institute of Child Health and Human
Development, with cooperative funding from 17 other agencies. Spe-
cial acknowledgment is due Ronald R. Rindfuss and Barbara
Entwisle for assistance in the original design. Persons interested in
obtaining data files from Add Health should contact Add Health,
Carolina Population Center, 123 W. Franklin Street, Chapel Hill,
NC 27516-2524 (<www.cpc.unc.edu/addhealth/contract.html>).
The authors thank Constantijn Panis for his advice and guidance
regarding study methods, and Elizabeth Terry-Humen for her valu-
able comments regarding conceptual design.
Author contact: jmanlove@childtrends.org
275